pacemaker - artificial pump to the heart, this contained definition, components,working, types, indication, methods of pacaing, temporary and permanent pacemaker, signs of failure of pacemaker , medical and nursing management of patient with pacemaker.

1. PACEMAKER
Submitted to : -
Mrs. Mamta Toppo
Associate Professor,
College of nursing
RIMS, Ranchi
Submitted by :
Muskan Kumari
Roll no. – 8
Basic B.sc nursing 3rd year ( 17-21)
College of nursing
RIMS, Ranchi

2. CONTENTS
 Introduction
 Definition
 Components of pacemaker
 How pacemaker works ?
 Types of pacemaker
 Indications of permanent
pacemaker
 Indications of temporary
pacemaker
 Methods of pacing
 Pacing Mode
 Causes for a pacemaker
failure
• Signs of pacemaker failure
• Nursing diagnosis
 Nursing management
 Complications
 Care of implanted pacemaker
 Patient and family teaching
 Summary
 Evaluation
 New Research done on it
 Reference
 Bibliography

3. INTRODUCTION
Pacemaker are the electrode devices that can
be used to initiate the heartbeat when the
hearts intrinsic electrical system cannot
effectively generate a rate adequate to
support cardiac output.

4. DEFINITION
Pacemaker is an
electronic device
used to pace the
heart when the
normal conduction
pathway is
damaged or
diseased.

5. COMPONENTS OF PACEMAKER
• Pulse generator
• Pacemaker
electrodes

6. HOW PACEMAKER WORKS ?
 A pacemaker consists of a battery, a computerized
generator and wires with sensors at their tips ( called
as electrodes ).The battery powers the generator
and both are surrounded by a thin metal box.The
wires connect the generator to the heart.
 A pacemaker helps monitor and control the
heartbeat.The electrodes detect heart’s electrical
activity and send data through the wires to the
computer in the generator. If heart rhythm is
abnormal, the computer will direct the generator to
send electrical pulses to heart.The pulses travel
through the wires to reach the heart.

7. HOW PACEMAKER WORKS ?

8. TYPES OF PACEMAKER
1. Permanent pacemaker
2. Temporary pacemaker

9. PERMANENT PACEMAKER
 It is implanted totally in the body.
 The power source is implanted
subcutaneously usually over the pectoral
muscle on the patient non dominant side.

10. TYPES OF PERMANENT PACEMAKER
1) Single-chamber pacemaker :- In this type, only
one pacing lead is placed into a chamber of the
heart, either the atrium or the ventricle.
2) Dual-chamber pacemaker :-Wires are placed in
two chambers of the heart. One lead paces the
atrium and one paces the ventricle. It closely
resembles the natural pacing of the heart.
3) Rate-responsive pacemaker :- It has sensors
that detect changes in the patient’s physical
activity and automatically adjust the pacing
rate to fulfill the body’s metabolic needs.

13. INDICATION OF PERMANENT
PACEMAKER THERAPY
1. Chronic atrial fibrillation with slow
ventricular response
2. Hypersensitive carotid sinus syndrome
3. Fibrosis or Sclerotic changes of cardiac
conduction system
4. Sick sinus syndrome
5. Tachyarrhythmia
6. Third degreeAV block

14. TEMPORARY PACEMAKER
 It is one that has the power source outside
the body. It can be used temporarily, either
supportively or prophylactically, until the
condition responsible for the rate or
conduction disturbance resolves.

15. TYPES OF TEMPORARY PACEMAKER
1) Transvenous invasive pacemaker :- It consists of
lead or leads that are threaded transvenously to
the right atrium and or right ventricle and
attached to external power source.
2) Transthoracic invasive pacing :- It is achieved by
attaching an atrial and ventricle and attached
to epicardium during heart surgery.The leads
are passed through the chest wall and attached
to the external power source.
3) Trans cutanoeus pacemaker :- It is used to
provide adequate heart rate and rhythm to the
patient in and emergency situation.

16. INDICATION OF TEMPORARY
PACEMAKER THERAPY
1. Maintenance of adequate heart rate and
rhythm during special circumstances such as
surgery and postoperative recovery, cardiac
catheterization or coronary angioplasty.
2. Before implantation of a permanent
pacemaker.
3. As prophylaxis after open heart surgery.
4. Acute anterior MI with second degree or
third degreeAV block or bundle branch
block.

18. METHODS OF PACING
1. TRANSVENOUS PACEMAKERS :- It involves
threading an electrode catheter through a
vein into the right atrium or right ventricle.
Five different veins can be used .
- Antecubital approach
- Femoral approach
- Subclavian
- Internal jugular
- External jugular

20. 2. EPICARDIAC PACEMAKERS
 In this case, the wires are attached to the
endocardium and are brought through a
surgical incision in the thorax.
 These wires are connected to an external
pulse generator.
 Commonly seen after cardiac surgery.

22. 3. TRANSCUTANEOUS PACING
 TRANSCUTANEOUS PACING is a temporary
means of pacing a patient’s heart during an
emergency and stabilizing the patient until a
more permanent means of pacing is
achieved.
 The most common indication for
transcutaneous pacing is an abnormally slow
heart rate.

24. 4. TRANSTHORACIC PACING
 It is placed in emergency via a long needle,
using a subxyphoid approach.
 The wire is then placed directly into the right
ventricle.

25. PACING MODE
 The pacing mode is described with a 4 – or 5 – letter
code ( eg., DDDR ), in which the first position identifies the
chamber paced ( A for atrium,V for ventricle, D for
dual/both ), the second position indicates the chamber
sensed, the third position denotes the device response to
sensed events ( I for inhibit,T for trigger, or D for dual ),
the fourth position indicates whether rate response is on,
and the fifth position ( when used ), indicates whether
multisite pacing is employed in the atrium ( A ), ventricle (V
), or both ( D ).
 In response to a sensed intracardiac signal, a pacemaker
may inhibit output, trigger output, or pace in different
chamber after a timed delay.This function is governed by
the programmed pacing mode.

26. COMMON PACING MODES

27. CAUSES FOR A PACEMAKER FAILURE
 Battery depletion
 Loose or broken wire between the pacemaker
and the heart
 Electronic circuit failure resulting from a break in
wire insulation or a fracture in the wire
 Electrolyte abnormality ( such as high potassium
in the blood )
 A pacemaker lead getting pulled out of position
 A change in your condition that needs
pacemaker reprogramming

28. SIGNS OF PACEMAKER FAILURE
 Dizziness, lightheadedness
 Fainting or loss of consciousness
 Palpitations
 Difficulty in breathing
 Slow or fast heart rate, or a combination of
both
 Constant twitching of muscles in the chest or
abdomen
 Frequent hiccups

29. NURSING DIAGNOSIS
 Acute pain related to insertion site and
prescribed post procedure immobilization.
 Impaired physical mobility related to
incisional site pain, activity restrictions.
 Risk for infection related to operative site.
 Risk for ineffective therapeutic regimen
management related to insufficient
knowledge of activity restrictions,
precautions.

30. NURSING MANAGEMENT
 Preoperative care
 Explain the procedure, type and technique of
pacemaker to the patient.
 Explain the cost of the procedure and hospital stay.
 Explain the process of the pacemaker insertion.
 Reassure the patient.
 Obtain written consent from the patient and from
nearest relative.
 Remove the dentures, jewellery and contact lens.
 Clean and shave the area.
 Check vital signs : temperature, BP, pulse and
respiration.

31. Intra-operative-care
 Check serology : HIV, HbsAg, HCV and others.
 Start an IV line with 5% Dextrose solution or normal saline
solution.
 Check the battery in pulse generator.
 Prepare the emergency cart, the defibrillator and jelly, and the
ECG monitor.
 Set up all equipment for the insertion of the pacemaker.
 The nurse should know about the pacemaker generator including
the power switch, indicator light for pacing and sensing, stimulus
output dial, sensitivity dial, and their proper settings.
 Assist the doctor and the scrub nurse during the procedure step
by step.
 Observe vital signs and observe ECG monitor carefully for
arrhythmias and other complications.

32. POST OPERATIVE CARE
 Receive the patient.
 Keep the patient in comfort position.
 Record the pacing parameters.
- Receiving time
- Patient’s heart rate
- other routine care
 Immobilize the affected part and keep in supine position
but allow the movement of finger and ankle joint.
 Monitor vital signs, heart rate and rhythm.
 Prevent infection and watch for complications.
 Take ECG and X-ray of chest.

33. COMPLICATIONS
 Hematoma
 Pneumothorax
 Cardiac perforation
 Ventricular atrophy and tachycardia
 Infection
 Movement or dislocation of lead
 Venous occlusion

34. CARE OF IMPLANTED PACEMAKER
 Follow your doctor’s directions carefully for wound care. If there is a
dressing, ask whether you should remove it or keep it until your next
visit.
 Take your temperature everyday and check your incision for signs of
infection.
 Keep your cell phone away from your pacemaker. Don’t carry the phone
in your shirt pocket over the pacemaker.
 Before you have any treatment, tell all health care providers, including
your dentist, that you have a pacemaker.
 Stay away from strong magnets.
 Make regular follow – up appointments with your doctor. He /She will
check the pacemaker to make sure it’s working properly.
 Carry pacemaker information card at all the times.
 Don’t drive until your doctor says it’s ok.
 If any complications arises, report the physician immediately.

35. PATIENT AND FAMILY TEACHING
• Maintain follow up care with a physician to check the
pacemaker site and begin regular pacemaker
function checks.
• Watch for signs of infection at incision site redness,
swelling dressing.
• Keep incision dry for 1 week after implantation.
• Avoid lifting operative site arm above shoulder level
until approved by care provider.
• The patient should be taught how to take the pulse.
• Carry pacemaker information card at all the times.

36. SUMMARY
• A pacemaker is a small device implanted in
the chest. It sends electrical signals to start or
regulate a slow heart beat. It’s most often
placed in the chest just under the collarbone.
• Pacemakers are used to treat arrhythmias, or
abnormal heart rhythms, and they help in
monitoring the heart rhythm.
• Pacemaker can sense when the heart’s
natural rate falls below the rate that has been
programmed into the pacemaker.

37. EVALUATION
 Introduce pacemaker.
 Define pacemaker.
 What are the components of pacemaker ?
 How pacemaker works ?
 What are the types of pacemaker ?
 Enlist the indications of permanent pacemaker and temporary pacemaker.
 What are the methods of pacing ?
 What are pacing modes ?
 What are the causes for a pacemaker failure ?
 What are the signs of pacemaker failure ?
 What are the complications of pacemaker ?
 What are the nursing diagnosis ?
 Discuss the nursing management of pacemaker.
 How the patient will take care of implanted pacemaker ?
 What should be the patient and family teaching given on pacemaker ?

38. NEW RESEARCH DONE ON IT
 Glenfield Hospital has become the first hospital in
the UK and Ireland to implant the world’s smallest,
wireless pacemaker – the size of a large vitamin –
into a patient’s heart.
 According to a new study by scientists at the UC San
FranciscoWeill Institute for Neurosciences is that
Irregular circadian rhythm in older adults associated
with increased risk of Parkinson’s disease.
 Pacemakers and other cardiac devices can help solve
forensic cases, according to a study presented at
EHRA EUROPACE- CARDIOSTIM 2017. Devices
revealed the time and cause of death in some cases
where autopsy failed to do so.

41. REFERENCE
 BOOKS
 INTERNET
 DISCUSSION
WITH TEACHER

42. BIBLIOGRAPHY
 Ansari Javed, textbook of medical surgical
nursing, volume – 2, PV publications, page
no- 1788 to 1798.
 Brunner and Suddarth’s ‘Textbook of Medical
Surgical Nursing’, South Asia edition, volume
– 2,Wolters kluwer publications, page no –
1231 to 1245.
 www.wikipedia.com
 www.slideshare.com
 www.ncbi.nlm.nih.gov